Pediatric Exam development

Energy (Calories)

• Term neonates: Need $100-120$ kcal/kg per day.
• Preterm neonates: Need $100-150$ kcal/kg per day.
• Extreme preterm neonates: Need $140-150$ kcal/kg per day.
• Children with CHF: Need $160-180$ kcal/kg per day.
• Caloric content of nutrients:
  • Protein (Amino acids): $4$ Kcal/g
  • Carbohydrate: $4$ Kcal/g
  • Lipids: $9$ Kcal/g

Breast Milk

• Consists of:
  • Colostrum:
    • First form of milk after delivery.
    • Rich in proteins and immunoglobulins (IgA).
  • Foremilk: Available at the start of feeding.
  • Hindmilk: Available at the end of feeding; rich in fat.
• Breast milk vs. standard formula:
  • Calories: Both have $67$ Kcal / 100 cc.
  • Lactose: High in breast milk, low in formula.
  • Protein (casein/whey): $40/60$ in breast milk (low casein), $80/20$ in formula (high casein).
  • Vitamin K: Low in breast milk.
  • Vitamin D: Low in breast milk; low in formula.
  • Vitamin C: High in breast milk, low in formula.
  • Iron: Low in breast milk but with good absorption; low in formula with bad absorption.
  • Carbohydrate: Same in both.
• Benefits of breast milk:
  • Provides good nutrition.
  • Immunological & antimicrobial protection (IgA & defensive factors).
  • Facilitates gut growth and provides digestive enzymes.
  • Better for development and intellectual outcome.
  • Improves the mother-baby bond.
  • Protects against necrotizing enterocolitis (higher incidence in non-breastfed babies).
  • Improves tolerance for enteral feeds.
  • Decreases the risk of allergy, eczema, and asthma.
  • Decreases the risk of obesity.
  • Decreases the risk of sudden infant death syndrome.
  • Post-delivery: Decreases the risk of post-partum hemorrhage.

Signs of Successful Breastfeeding

• Frequency: $8 – 12$ feeds per day (every 2-3 hours) for the first 2 months.
• No breast pain during lactation.
• Breasts are softer after breastfeeding.
• Adequate urine output: $6-8$ wet diapers/day.
• Frequent swallowing during feeding (audible gurgling).
• Adequate stooling.
  • Typical stool characteristics: Yellow, seedy stool typically seen on the 3rd or 4th day of life.
• Weight loss should not exceed $8 – 10$% of birth weight in the 1st week.
• Expected weight gain: $15 - 30$ g/day.
• Well-hydrated baby: Good skin turgor and moist mucous membranes.
• Baby sleeps: $1.5 – 2$ hours after each feed.

Coordination of Sucking, Swallowing & Breathing

• Starts at week $33-34$.
• Babies born before coordination should not be breastfed due to high risk of aspiration.
  • Respiratory Rate < $70$ → No risk of aspiration (Can be fed PO).
  • Respiratory Rate $70-80$ → use NasoGastric tube.
  • Respiratory Rate > $80$ → NPO & must be given only IV fluid.

Contraindications of Breastfeeding

• Galactosemia:
  • Breastmilk contains lactose which is broken down into galactose and glucose.
  • Galactose builds up due to lack of enzymes that break it down which could cause organ damage if levels are high.
  • Babies must be fed with lactose-free formula.
• PhenylKetonUria (PKU)
• Certain maternal medications: Chemotherapy, radiation.
• Active TB
• HIV
• Active herpes simplex lesions on the breast

Cow’s Milk Contraindications (First Year of Life)

• High solute loads: can cause renal problems.
• Insufficient vitamins (A, D).
• Fat is poorly tolerated.
• Insufficient calcium → hypocalcemia → seizures.
• May cause sensitization to cow’s milk proteins in gut → microhemorrhages → severe anemia.

Weaning Food

• Switching from breast milk/formula to other foods/fluids.
• Exclusive breastfeeding's ability to meet requirements becomes limited with increasing infant age.
• Gradual process starting at 6 months of age.
  • If weaning starts before 6 months: Risk of food allergy.
• Start weaning with vegetables that aren't so sweet, such as broccoli, cauliflower and spinach.
• Do not give your baby honey: Risk of botulinum infection → bilateral weakness.
• In vegetarian diet → vitamin B12 deficiency

Types of Formula

• Soya based formula
  • Indications: Cow milk protein allergy, Galactosemia, Lactase deficiency
• Lactose-free formula
  • Indications: Galactosemia, Lactase deficiency
• Partial hydrolyzed formula
  • Indication: Cow milk protein allergy
• Extensively hydrolyzed (amino acid) formula
  • Indications: Cow milk protein allergy, Multiple food allergy
• Thickened (anti-reflux) formula
  • Indication: GastroEsophageal Reflux Disease
• Low phenylalanine formula
  • Indication: Phenylketonuria
• Gluten-free formula
  • Indication: Celiac disease

Vaccine

• A product (e.g., dead or weakened organism) that provides immunity from a disease.
• The immediate goal is prevention of disease.
• The ultimate goal is eradication of disease.
• Smallpox eradicated in 1980.

Types of Immunity

• Passive:
  • Means of acquisition: Receiving performed antibodies.
  • Onset: Rapid.
  • Duration: Short span of antibodies.
  • Examples: IgA in breast milk, Maternal IgG crossing placenta, Antitoxin.
• Active:
  • Means of acquisition: Exposure to exogenous antigens.
  • Onset: Slow.
  • Duration: Long-lasting protection (memory).
  • Examples: Natural infection, Vaccines, Toxoid.

Types of Vaccines

• Live-attenuated:
  • Definition: Microorganism attenuated (weakened) in a laboratory.
  • Contraindicated in cases of immunodeficiency and pregnancy
  • Examples: BCG, MMR, OPV, Rota, Varicella, Oral typhoid, Yellow fever, Nasal Influenza virus
• Inactivated:
  • Definition: Pathogen is inactivated by heat or chemicals.
  • Examples: DTaP, Hepatitis A, Influenza virus, Salk (IVP)
• Genetically engineered (recombinants antigens):
  • Definition: Hepatitis B Virus, Human Papilloma Virus
• Subunit:
  • Definition: Includes only the antigens that best stimulate the immune system
  • Examples: HBV (HBsAg), acellular Pertussis (aP), Neisseria meningitidis, Hib
• Conjugated vaccine:
  • Definition: Combines a weak antigen with a strong antigen
  • Examples: Neisseria meningitidis, Hib, Streptococcus pneumonia
• Possible side effects to all vaccines:
  • Local reactions to injectable vaccines.
  • Anaphylaxis to the vaccine or one of it’s components (contraindications for further similar doses).
  • Syncope.
  • Fever

The followings are not contraindications to vaccine administration

• Mild illness with or without fever.
• Breast feeding.
• Preterm birth.
• Local reaction or fever after previous vaccine.
• Penicillin allergy
• Concurrent antibiotics use
• Family history of seizure
• Controlled seizures
• IgA deficiency

Jordan National Program

• Vaccination schedule details are not included in provided text.

Some Vaccines

• BCG:
  • Reduces disseminated and life-threatening manifestations of TB in young children:
    • Meningitis
    • Miliary TB
    • 80% efficacy
  • Specific adverse events:
    • 1%, localized abscess and lymphadenopathy, generally not serious → only conservative management
    • After several years of BCG → Osteitis
    • Disseminated (2 per 1 million)
• OPV/IPV:
  • Induces more immunity than IPV (intestinal and serum antibody response), herd immunity
  • More side effects than IPV → vaccine associated poliomyelitis
  • Better to use in outbreaks.
  • 3 serotypes
  • Efficacy 99-100%
  • OPV contraindications:
    • Immunodeficiency including antibody disorders
    • In a patient who has another family member who is immunocompromised
• DTaP:
  • Tetanus and Diphtheria booster every 10 years.
  • Acellular is better than cellular pertussis
  • Efficacy: 98-100% after 5 doses
  • Despite adequate immunization of pertussis; still can cause small outbreaks
  • Side effects:
    • Local reactions include whole limb swelling.
    • Brachial neuritis
    • Febrile seizures within 48 hrs ; more common than MMR
    • Hypotonic hyporesponsive episode
    • Fever 40.5 or higher within 48 hrs
    • Prolonged (>3hrs) inconsolable crying within 48 hrs
    • Encephalopathy
  • Contraindications:
    • Encephalopathy within 7 days of previous dose (to pertussis vaccine)
    • Children less than 1 year with evolving neurological disorder (to pertussis vaccine)
• Rota Virus:
  • Should not given for infants older than 15 weeks
  • Contraindications:
    • SCID
    • History of intussusception
  • Precautions:
    • Severe illness including gastroenteritis
    • Other types of immunodeficiency
    • Chronic GI illness
• MMR:
  • Efficacy after 1 dose 95%, 2 doses 99%
  • Side effects:
    • Arthralgia or arthritis (7-21 days after the vaccine)
    • Measles-like rash
    • Febrile seizures
    • Orchitis, parotitis (mumps component)
    • Thrombocytopenia (measles component)
• HepB:
  • Efficacy 90-95%.
  • Protection for 20 years or longer
  • For infants born to HBsAg + mothers:
    • HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth
• Varicella vaccine:
  • Live attenuated vaccine
  • Not included in National Jordan program
  • All children receive 2 doses:
    • Dose 1: 12–15 months of age
    • Dose 2: 4–6 years of age
  • Minimum age for varicella vaccine is 12 months
  • Maximum age for varicella vaccine is 12 years
  • If the child not infected with varicella, recommend the mother to vaccinate her child

Growth Assessment

1. Weight:
   • Infants gain 25–30 g/day for the first 3 months of life
   • Normal birth weight 2.5 - 4 kg
   • 4-5 months Doubling of weight
   • 1 year Tripling of weight
   • 2 years Quadruple of weight
   • After 2 years of age Weight = $(2 \times age) + 8$
2. Height: Gain 1 cm/week (during the first 3 months then things change)
   • Newborn 50 cm
   • 1st year 75 cm
   • 2nd year 87.5 cm
   • 3rd year 94 cm
   • 4th year 100 cm
   • 14 years old 150 cm (tripling of height)
   • After 2 years of age Height = $(5 \times age) + 80$
3. Head circumference:
   • In 1st 3 months → ↑ 2 cm/month
   • In the next 3 months → ↑ 1 cm/month
   • In the next 6 months → ↑ 0.5 cm/month
   • In the second year → 0.5 cm / 3 moths ( 2 cm in all the year )
   • Newborn 35 cm
   • 6 months 44 cm
   • 1 year 47 cm

Fontanelles

Primitive Reflexes

Reflex actions originating in the CNS that are exhibited by normal infants

Gross Motor Milestones

• Red flags in gross motor development:
  • 6 month → not sitting
  • 15 month → not walking
  • 2 years → not climbing stairs
  • 3 years → not stand on one foot
  • Early hand dominance (before 18 months of age)
  • Any asymmetries to movement

Fine Motor Milestones

• Red flags in fine motor development:
  • Lack of steady head control beyond 2 months
  • Persistent hand fisting beyond 3 months of age
  • 10 month → no pincer
  • 20 month → unable to remove socks
  • 2 years → no scribble
  • 3 years → not copy circle
  • 4 years → not copy square

Social Milestones

• Red flags in social–emotional development:
  • Lack of smiling at 6 months of age
  • Rarely responding to name when called at 12 months of age

Language & Communication Milestones

• (Details missing from provided text)